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• <br /> • <br /> • <br /> Application for Onsite For Cityl5e only: nacestamp: - <br /> Wastewater Treatment System city of . <br /> Date Received - RECE -V-E. <br /> MARION COUNTY PUBLIC'WORKS ' Received by <br /> BUILDING INSPECTIOND <br /> _ DIVISION Zoning by p MA �o q l� <br /> • 5155 Silverton Rd NE Fee y o 2 <br /> Salem OR 97305 • <br /> (503)588-5147Fax(503)588-7948 . Receipt# MARION (J U NTY <br /> WWII'.co.marion.or.us/PW/ Buildinglnspection Activity## ��� � INSPECTION <br /> A:Property Owner Information • • <br /> Name • Mailing Address City,State,and Zip (Area Code)Phone# <br /> - _ • B.Legal Property Description <br /> Legal Description • Tax Lot Acreage or Lot Size <br /> I. _ . <br /> Subdivision Name Lot Block <br /> 5138 Q r. . C7\(\r), . • <br /> Property Address City State Zip Code <br /> Directions to Property: - <br /> C.Existing Facility/Proposed Facility/.Water Information <br /> • <br /> Existing Facility: Proposed Facility: Water Supply: <br /> ❑Sin&eFamily Residence ❑ SingleFatp�lyResidence ['Public • <br /> ,(mac Name <br /> Number of Bedrooms Number of Bedrooms Private <br /> ❑'Other EJ Other - ( Well,S ring,Shared. • <br /> D.Type of Application' <br /> Zf•Site Evaluation ❑ Renewal Permit <br /> ❑Authorizatioa Notice for: <br /> ❑ Construction Permit ❑ Permit Reinstatement ❑ Replacing a Dwelling <br /> ❑ Repair Permit • ❑ Permit Transfer ❑ The Addition of One or More Bedrooms <br /> ❑ Major ❑ Minor ❑ Existing System Evaluation ❑ Personal Hardship <br /> • ❑ Alteration Permit ❑ Record Review ❑ Temporary Housing <br /> ❑ Major ❑ Minor ❑ Other . ❑ Connecting to an Existing System Never in Use ' <br /> (over 5-yrs old). <br /> ❑ Other—Please Specify <br /> If the required fee and attachments are not included with this application, it will be returned to you as incomplete. <br /> . Post the orange card at the entrance to the property. Flag the test holes. ,- <br /> By my signature,I certify that the information I have furnished is correct, and hereby grant Marion County,authorized agent of the • <br /> Department of EnvironmentailQuality,permission to enter onto the above described property for the sole purpose of this.application. <br /> I .L/1/ <br /> t <br /> Apo cant's Name—Please Print Legi Applicant's Phone Number DEQ Lic.# (if applicable)" . <br /> • Applicant's Mailing Address - '. _ . ' <br /> • <br /> Signature Date: . CCB# (if applicable) <br /> Applicant is the 0 Owner El Authorized Representative 0 Authorization to Apply form Attached . <br />